How to Coordinate Care Between OB/GYN and Psychiatrist for Medications During Pregnancy and Breastfeeding

When you’re pregnant or breastfeeding and need psychiatric medication, you’re not just managing your mental health-you’re managing two lives. The stakes are high. Untreated depression or anxiety can lead to preterm birth, low birth weight, or even postpartum psychosis. But the wrong medication? It could affect your baby’s development. That’s why coordinating care between your OB/GYN and psychiatrist isn’t optional-it’s essential.

Why Coordination Isn’t Just Helpful, It’s Life-Saving

Most women don’t realize that 1 in 5 experience a mental health condition during pregnancy or the year after birth. Yet, nearly half of those women stop their medication because they’re afraid of harming their baby. That fear often comes from fragmented care: your OB/GYN says one thing, your psychiatrist says another, and you’re left confused.

Data from the American College of Obstetricians and Gynecologists (ACOG) shows that when OB/GYNs and psychiatrists work together, medication discontinuation drops from 42% to just 18%. Postpartum depression symptoms decrease by 37%. That’s not a small win-it’s a life-changing shift.

The real issue? Most OB/GYNs treat perinatal depression alone. But when it comes to bipolar disorder, severe anxiety, or treatment-resistant depression, they’re not equipped to make the final call on medication. That’s where the psychiatrist comes in.

What Medications Are Safe? The Science Behind the Choices

Not all antidepressants are created equal during pregnancy. Some cross the placenta easily. Others barely do. And some are known to increase the risk of birth defects. So how do you know what’s safe?

The gold standard, backed by over 147 studies and endorsed by ACOG in 2023, is sertraline or escitalopram. Why these two?

• Sertraline has a 0.5% absolute risk increase for cardiac defects-compared to a 1% baseline risk in the general population. That’s a tiny bump.
• It’s 98% protein-bound, meaning very little passes into the baby’s bloodstream.
• It has minimal drug interactions and a half-life of 26 hours-perfect for stable dosing during pregnancy.

Avoid paroxetine. The FDA updated its labeling in January 2024 to warn that paroxetine increases the risk of heart defects. Even small doses carry more risk than other SSRIs.

For bipolar disorder, mood stabilizers like lithium or lamotrigine are often continued-but valproate is a hard no. It raises the risk of major birth defects to 10.7%, compared to 2-3% normally. If you’re on valproate and planning pregnancy, switching before conception is non-negotiable.

The 5-Step Coordination Protocol You Need to Follow

ACOG’s 2023 guidelines lay out a clear, step-by-step process. Here’s how it works in real life:

1. Preconception planning (3-6 months before trying): If you’re thinking about pregnancy, schedule a joint visit with both providers. Talk about your current meds, past side effects, and relapse history. This isn’t just advice-it’s a documented plan.
2. First coordination meeting by 8-10 weeks: By this point, your body has changed. Blood volume has increased by 40-50%. Your kidneys are filtering faster. Medication levels drop. Your psychiatrist needs to adjust your dose before you even feel off.
3. Regular check-ins every 4 weeks: For stable cases. If you’re struggling, weekly. No exceptions. Pregnancy isn’t a time to wait and see.
4. Use standardized tools: Ask for the ACOG Reproductive Safety Checklist. It rates risks on a 1-10 scale-for both your chance of relapse and your baby’s exposure risk. It turns emotion into data.
5. Document everything: Your OB/GYN’s note should say: “Sertraline 75mg daily. Maternal relapse risk without treatment: 65%. Risk of cardiac defect with treatment: 0.5%.” That’s the kind of clarity that saves lives.

What Happens During Breastfeeding?

Many women panic when they find out they can’t take certain meds while nursing. But here’s the truth: most SSRIs are safe. Sertraline and escitalopram show up in breast milk at less than 1% of the maternal dose. That’s lower than what you’d get from a baby’s own metabolism.

Avoid fluoxetine-it lingers in breast milk longer and can build up in the baby. Clonazepam is risky if used daily. But if you need a benzodiazepine for severe anxiety, a single nightly dose under psychiatrist supervision is acceptable for short periods.

The National Pregnancy Registry for Psychiatric Medications tracks over 15,000 pregnancies and breastfeeding cases. Their 2023 data shows no increase in developmental delays or feeding issues with sertraline use during lactation.

The Hidden Barriers-And How to Beat Them

Coordination sounds simple. But in practice? It’s messy.

• Electronic records don’t talk: 67% of providers say their OB/GYN and psychiatric systems can’t share notes. Solution? Bring printed summaries to every appointment. Ask your psychiatrist to email a summary directly to your OB/GYN’s office.
• Insurance delays: 57% of patients wait over 14 days for prior authorization to see a psychiatrist. If you’re pregnant, call your insurer daily. Ask for a medical necessity override. Mention ACOG guidelines-they’re binding in many states.
• Conflicting advice: On Reddit’s r/PPD community, 42% of users got contradictory info. One woman stopped sertraline because her OB/GYN said “it’s risky,” while her psychiatrist said “it’s safer than relapse.” She ended up hospitalized. Don’t let this be you.

If your OB/GYN refuses to coordinate, ask for a referral to a maternal-fetal medicine specialist. 92% of these specialists endorse joint care. If your psychiatrist won’t talk to your OB/GYN, ask them to sign a release form. It’s legal. It’s standard.

Real Stories, Real Outcomes

Kaiser Permanente’s integrated program saw 89% patient satisfaction. Why? Because their patients had joint video visits. Both providers in the same room. One plan. One voice.

One patient, 32, with a history of bipolar disorder, was on lithium before pregnancy. Her OB/GYN wanted to stop it. Her psychiatrist said no-lithium’s risk is 1.5% for heart defects, but relapse risk is 70%. They worked together. She stayed on a low dose, monitored weekly. Her baby was born at 39 weeks, healthy. No complications.

Another woman, 28, stopped her SSRI because her mom said “meds are poison.” Her OB/GYN didn’t push back. She had a severe postpartum episode, couldn’t bond with her baby, and spent three weeks in a psychiatric unit. That’s preventable.

What’s Changing in 2026?

The system is getting better. Epic Systems’ Perinatal Mental Health Module, launched in 2023, now automatically alerts psychiatrists when an OB/GYN prescribes antidepressants. Over 1,200 hospitals use it.

The FDA now requires all psychiatric medication labels to include coordination recommendations. Sertraline’s label says: “Coordination with obstetric provider recommended for dose adjustment beginning at 20 weeks due to increased clearance.” That’s huge.

And in 2024, Medicare and Medicaid started rewarding clinics that document coordinated care. Practices with 90%+ communication between OB/GYNs and psychiatrists get a 5% reimbursement bonus. That’s pushing hospitals to finally fix this.

What You Can Do Today

If you’re pregnant, planning pregnancy, or breastfeeding and taking psychiatric medication:

• Ask your OB/GYN: “Have you coordinated with my psychiatrist?”
• Ask your psychiatrist: “Can you send a summary to my OB/GYN?”
• Bring the ACOG Reproductive Safety Checklist to your next appointment.
• Know your medication’s protein binding, half-life, and lactation category. Look it up on the National Pregnancy Registry website.
• If you’re told to stop meds-get a second opinion. The risk of no treatment is often higher than the risk of the medication.

Your mental health matters. Your baby’s health matters. And when these two are handled together? You get the best possible outcome.